Provider Demographics
NPI:1144244278
Name:BLANKS, JEFF P (MFT)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:P
Last Name:BLANKS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14140 BEACH BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4453
Mailing Address - Country:US
Mailing Address - Phone:714-896-7574
Mailing Address - Fax:
Practice Address - Street 1:17542 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3155
Practice Address - Country:US
Practice Address - Phone:949-525-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25338106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist